A Comparison of Intraoperative Prothrombin Protein Concentrate Dosing Strategies in Cardiac Surgery

Introduction: Excessive bleeding following cardiac surgery affects up to 15% of patients and is commonly managed with blood products. Four-factor prothrombin complex concentrate (PCC) has demonstrated superior hemostatic effectiveness and reduced transfusion requirements compared to blood products. However, the optimal dosing of PCC has yet to be evaluated. This study evaluates the clinical and economic impact of a revised PCC dosing protocol implemented at a tertiary academic medical center.


Methods: A retrospective cohort analysis was conducted on cardiac surgery patients requiring cardiopulmonary bypass who received peri-operative PCC between October 2024 and March 2025. Patients were divided into two groups: pre-protocol (three vials, ~1500 Factor IX international units (IUs) and post-protocol (two vials, ~1000 IUs) evaluated on a 3-month pre/post analysis. Clinical outcomes included need for re-dosing PCC, post-operative blood product within 72 hours, and need for re-operation. Medication administration charges and average wholesale price was used for assigning cost. Cost was calculated on a per patient basis. Comparisons were completed with independent samples t-test or Fisher’s Exact test, as appropriate.


Results: A total of 150 patients were included (82 pre-protocol, 68 post-protocol). The cohorts were similar at baseline in regard to age (63 ± 12 v. 66 ± 10), weight (91kg ± 22 vs. 92kg ±21), male gender (73% v. 67%) and aortic surgical involvement (78% v. 85%). Intraoperative blood salvage volume (791mL ± 303 v. 880mL ± 439, p=0.16) and estimated blood loss (110mL ± 223 v. 69 mL ± 170, p=0.22) was not significantly different. The percentage of patients requiring post-operative transfusion with packed red blood cells (48% v. 40%, p=0.41), platelets (20% vs. 22%, p=0.84) and plasma (20% vs. 21%, p=1) did not differ between groups. There was no difference in re-dosing (9.8% v. 11.8%, p = 0.79) or re-operation (14.8% v. 11.8%, p = 0.64) between the pre and post-protocol groups. The mean vials administered decreased from 3 ± 1 to 2 ± 1, representing a cost reduction of $2,041 per patient ($6603 ± 1994 v. $4563 ± 1969, p< 0.01).


Conclusions: Implementation of a two-vial PCC protocol significantly reduced drug utilization and cost without compromising effective hemostasis in cardiac surgery.